Wireless Technologies Linked to Improved Heart Disease Outcomes

Patrice Wendling

September 23, 2017

MORGANTOWN, WV — A new study suggests mobile health (mHealth) technologies like smartphone-connected monitors, activity trackers, and pocket echocardiography may hasten diagnosis and treatment of patients with rheumatic and structural heart disease (SHD)[1].

Patients assessed at mHealth-equipped clinics compared with those seen at standard clinics experienced a near halving in the time to referral for valvuloplasty or valve replacement and in the risk for rehospitalization and/or all-cause death during follow-up.

"Even at tertiary centers, some of these technologies are not being utilized routinely, and this practice needs to stop. We need to be more intelligent about using the right kind of tools and new technologies for an expedited intervention," senior author Dr Partho Sengupta (West Virginia University School of Medicine, Morgantown) told theheart.org | Medscape Cardiology.

Results from the American Society of Echocardiography Foundation-Mobile Health in Structural Heart Disease (ASEF-VALUES) program were published online in JACC: Cardiovascular Imaging.

The findings are important, "since they show how wireless technologies may improve healthcare delivery," Dr Miriana Mirabel (Paris Cardiovascular Research Center, France) and Dr Luigi P Badano (University of Padova School of Medicine, Italy) write in an accompanying editorial[2]. "Point-of care enables a better triage of patients according to their disease severity in a more objective manner."

They note that this is the first study to report improved outcomes in patients undergoing a point-of-care diagnostic workup and that the advantages of mHealth would be particularly relevant in low- and middle-income countries, where the prevalence of noncommunicable diseases is rapidly increasing.

The study was conducted in Bangalore, India, where patients can wait up to 24 months for a cardiac procedure, but Sengupta argues its findings are equally relevant for many areas in the US where integration of portable, lower-cost mHealth tools could help bridge the gap in healthcare inequalities. Responding to the strong need in his own state, an outpatient SmartClinic was recently created where the stethoscope is a thing of the past.

"When I show patients with the pocket ultrasound that this valve isn't moving, this color isn't moving, they respond," he said. "These technologies allow us to develop a trust, an interaction that is better than just meeting and shaking hands, listening to them, and telling them you need to do more tests. That is very shaky ground.

"The first 15 minutes of the patient interaction are so critical that it kind of dictates the rest of the story of how they're going to be taken care of, what's their trust, what kind of therapeutic decisions are going to be taken, and their willingness to follow up."

mHealth-Enabled Clinics

The investigators, led by Dr Sanjeev Bhavnani (Scripps Clinic and Research Foundation, San Diego, CA), randomly assigned 253 consecutive patients (mean age 39 years; 42% female) with a new or established diagnosis of rheumatic and SHD to an initial evaluation with mHealth or standard care.

All mHealth clinics were designed to operate using only local power without WiFi and were equipped with the same devices: pocket echocardiography (VScan, General Electric), smartphone-connected oximetry and blood-pressure monitors (iHealth, San Francisco), smartphone-connected iECG (AliveCor, San Francisco), activity trackers (Ozeri, San Diego), and finger-stick B-type natriuretic peptide (Alere Triage, Gurgoan, India).

Comprehensive transthoracic echocardiography conducted in all patients revealed SHD with mitral stenosis, mitral regurgitation, aortic stenosis, or aortic regurgitation in 57%, 42%, 23%, and 32%, respectively, with a similar prevalence between groups. Overall, 46% of patients exhibited NYHA class 2-3 symptoms.

At 12 months of follow-up, patients initially assessed with mHealth underwent treatment with valvuloplasty or surgical valve replacement at about the same rate as those assessed with standard care (34% vs 32%; adjusted hazard ratio 1.54; P=0.07), but the time to treatment referral was more than doubled in the standard-care cohort (83 vs 180 days; P<0.001).

The mHealth cohort also had a significantly lower risk of hospitalization and/or death (15% vs 28%; adjusted HR 0.41; P=0.013).

In subgroup analyses, use of iECG, pocket echocardiography, and activity monitors for 6-minute-walk tests were independent predictors of these outcomes.

Sengupta said they have not done a cost analysis but that intuitively this strategy would be cost-effective, given the improved long-term outcomes and potential for reduced testing. Many patients with valvular heart disease will claim to be asymptomatic but will become symptomatic very early on when put on the treadmill, he noted. "Why do you need to do a treadmill test when you can get quantitative data that will be a way to classify these patients as symptomatic at the first visit?"

Mirabel and Badano write that mHealth is thought to be less costly than conventional care, but affordability for both patients and local healthcare systems has not been explored.

They note that the study was conducted though a tertiary-care teaching institution and local physicians were supervised by highly trained sonographers, raising questions about its generalizability to settings with less skilled and trained workforces.

Finally, the study raises questions about the curriculum required to ensure proficiency of point-of-care technologies, especially echocardiography; how to assess cost-effectiveness across different healthcare systems; and how some countries would ensure standard of care when severe heart-valve disease or other noncommunicable diseases are diagnosed.

"Mobile health is a promising tool to ensure rapid and appropriate delivery of cardiac care that may help in filling the gap of fractured healthcare systems. Answering the aforementioned questions before launching any complex public-health intervention could make the difference between the success and the failure of mHealth in [low- and middle-income countries]," Mirabel and Badano conclude.

The study was funded by the American Society of Echocardiography Foundation and Sri Satya Sai Institute of Higher Medical Sciences. Device support was provided by General Electric Healthcare, CoreSound Imaging, and iHealth. Sengupta reports research grants from Heart Test Labs and Echo Sense and consulting for TeleHealth Robotics, Hitachi Aloka, and Heart Test Labs. Disclosures for the coauthors are listed in the paper. Mirabel and Badano report no relevant financial relationships.

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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